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Of Healthcare Punditry And Crystal Balls: Part 1

Of Healthcare Punditry And Crystal Balls: Part 1

It is that time of year when pundits of all sorts reflect on the past and prognosticate the future. In the spirit of the season, Strategic Insights joins in by summing up the past year in health care and readying its crystal ball for the next.

Medicare:

Medicare Advantage (MA) continued to enjoy a resurgence despite some of the financial realignment and policy changes that came to fruition over the past few years. MA saw its highest enrollment percentage of Medicare beneficiaries in 2015 with bright numbers expected for welcome season in 2016. While premium growth is not what plans want it to be, plans overall continue to enjoy profitability with the major reductions of the past few years tailing off.

Special Needs Plans (SNPs) cemented their status as favored sons and daughters of the Centers for Medicare and Medicaid Services (CMS), with a continued rollout of dual demonstration plans as well as the announcement of CMS’ intent to look at the discrimination SNPs face both within the Star program and how risk adjustment premium is set.

CMS must have been delighted, too, with the 2016 Star announcement. About 50% of plans are now achieving 4 or 5 Star status and an expectation of over 70% of beneficiaries are enrolling in such plans for 2016.

Risk adjustment in the MA world saw its first major change, with CMS announcing that the 2016 risk adjusted premium will be a blend of the traditional Risk Adjustment Processing System (RAPS) encounter information and the actual 837 encounter data submissions.

CMS continued its rigorous compliance and audit regime, by announcing much more complex universe submission requirements to further facilitate its increasing move to target audit samples to the likely non-compliant cases.

In an effort to wring some cost savings and quality out of the antiquated Medicare fee-for-service environment, Medicare also expanded its reform pilots.

Medicaid:

Medicaid as well as Medicaid managed care continued to see major growth, fueled for the most part by the Affordable Care Act (ACA) expansion. Medicaid state agencies continued to work closely with CMS on their rollout of the dual demonstration projects, although some states saw setbacks with anemic enrollments and some high-profile plan withdrawals in some states. CMS, too, remains disappointed that only about half of the states have expanded eligibility to the ACA levels.

The introduction of the so-called Medicaid “Uber rule” was perhaps the most notable Medicaid occurrence in 2015. Long frustrated by a lack of quality and accountability in Medicaid, the Uber rule will set strong standards on marketing, enrollment, minimum medical loss ratio, quality achievement, encounter data, and timeliness of case processing. Can anyone say “Medicare”?

Exchanges:

After its rocky start in 2014, 2015 was the year the Exchanges seemingly turned the corner. The great website fiasco was fixed. While below targets, enrollment is at respectable levels after two years and going into its third. So far, the predicted ‘rate death spiral’ has not come true, with premiums rising at percentages below historic annual trends.

But 2015 also saw some ominous signals for the Exchange world, including a huge shortfall in the risk corridor program and the announcement by United Healthcare that it may – may, mind you – exit the program in 2017 due to medical loss concerns.

CMS began building the blueprint for Exchange compliance and quality achievement as well, with strengthening network approaches, announcing the beginning of audit protocols, and beginning collection of quality data that will lead to a Star program and ratings in the future.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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